Byung Sung Kim

Ligamentous repair of acute lateral collateral ligament rupture of the elbow

BACKGROUNDnWe evaluated the clinical outcome and findings of ligamentous repair for acute posterolateral rotatory instability (PLRI) of the elbow.nnnMATERIALS AND METHODSnNineteen patients underwent lateral collateral ligament repair for acute PLRI. Ten male and nine female patients were observed for a mean of 9 months; their mean age was 46 years (14-70 years). The mean time from injury to operation was 8.1 days (1-18 days). The lateral pivot shift and varus stress test results were positive for all cases. We repaired the lateral ulnar collateral ligament with Ethibond in 6 cases and Bio-FASTak in 15 cases. We evaluated the range of motion, pain, and stability by the satisfaction of the patient, the Mayo Elbow Performance Score, and the Nestor grading.nnnRESULTSnThe lateral pivot shift test result was negative in all patients at the final follow-up. The mean elbow extension was 13°; flexion, 120°; supination, 74°; and pronation, 78°. Mild valgus laxity was noted in two patients who had mild pain on activity. The mean Mayo Elbow Performance Score was 86.9 points (65-100 points), with 13 excellent cases, 5 good cases, and 1 fair case. According to the Nestor grading, the results were rated excellent in 14 patients and good in 5. All patients were satisfied with their outcome in the subjective assessment. The complications were 1 case of knot irritation and 5 cases of ectopic ossification.nnnCONCLUSIONnWe obtained satisfactory outcomes with lateral collateral ligament repair for acute PLRI of the elbow.

Arthroscopically Assisted Reconstruction of Triangular Fibrocartilage Complex Foveal Avulsion in the Ulnar Variance-Positive Patient

PURPOSEnOur aim was to evaluate the clinical results of patients treated by arthroscopically assisted reconstruction of foveal avulsion injury of the triangular fibrocartilage complex (TFCC) using a suture anchor.nnnMETHODSnWe retrospectively reviewed the results of 15 patients (11 men and 4 women; mean age, 30.5 years) who underwent surgical procedures for the treatment of TFCC foveal avulsion at our hospital. The patients were followed up for a mean of 29 months. The patients had TFCC foveal avulsion caused by sprains (nxa0= 8), falls (nxa0= 4), playing baseball (nxa0= 2), and a motor vehicle accident (nxa0= 1). All the patients underwent magnetic resonance imaging. Radiographs obtained to assess ulnar variance (UV), ulnar-dorsal subluxation, and function of the wrist based on grip power; Disabilities of the Arm, Shoulder and Hand score; and Mayo wrist score were examined for all patients both preoperatively and postoperatively.nnnRESULTSnOn preoperative magnetic resonance imaging, TFCC foveal avulsion was observed in 13 of 15 cases. The mean UV value based on preoperative simple radiographic findings was 1.7 ± 1.0 mm, and dorsal subluxation at the distal ulna improved from 2.9 ± 3.0 mm to 0.2 ± 0.9 mm (Pxa0= .017). In all cases the distal radioulnar joint instability disappeared postoperatively. Grip power (compared with the uninvolved limb) was 79.3% preoperatively and 82.9% postoperatively (Pxa0= .086). The Disabilities of the Arm, Shoulder and Hand scores were 28.4 points preoperatively and 16.6 points postoperatively (Pxa0= .061). The Mayo wrist scores were excellent in 10 cases, good in 2, and fair in 3, and the mean score improved significantly from 64 points preoperatively to 84 points postoperatively (Pxa0= .007).nnnCONCLUSIONSnArthroscopic-assisted suture anchor reattachment of the TFCC in patients with traumatic TFCC foveal avulsion can prevent or reduce distal radioulnar joint instability and reduce pain even in chronic cases with positive UV.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

A Comparison of Ulnar Shortening Osteotomy Alone Versus Combined Arthroscopic Triangular Fibrocartilage Complex Debridement and Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

Background This study compared the results of patients treated for ulnar impaction syndrome using an ulnar shortening osteotomy (USO) alone with those treated with combined arthroscopic debridement and USO. Methods The results of 27 wrists were reviewed retrospectively. They were divided into three groups: group A (USO alone, 10 cases), group B (combined arthroscopic debridement and USO, 9 cases), and group C (arthroscopic triangular fibrocartilage complex [TFCC] debridement alone, 8 cases). The wrist function was evaluated using the modified Mayo wrist score, disabilities of the arm, shoulder and hand (DASH) score and Chun and Palmer grading system. Results The modified Mayo wrist score in groups A, B, and C was 74.5 ± 8.9, 73.9 ± 11.6, and 61.3 ± 10.2, respectively (p < 0.05). The DASH score in groups A, B, and C was 15.6 ± 11.8, 19.3 ± 11.9, and 33.2 ± 8.5, respectively (p < 0.05). The average Chun and Palmer grading score in groups A and B was 85.7 ± 8.9 and 84.7 ± 6.7, respectively. The difference in the Mayo wrist score, DASH score and Chun and Palmer grading score between group A and B was not significant (p > 0.05). Conclusions Both USO alone and combined arthroscopic TFCC debridement with USO improved the wrist function and reduced the level of pain in the patients treated for ulnar impaction syndrome. USO alone may be the preferred method of treatment in patients if the torn flap of TFCC is not unstable.

Subluxation of the Extensor Carpi Ulnaris Tendon Associated with the Extensor Digitorum Tendon Subluxation of the Long Finger

A twenty-year-old male visited our clinic with wrist and long finger metacarpophalangeal (MP) joint pain. Dynamic ultrasonography revealed sagittal band (SB) ulnar subluxation and extensor carpi ulnaris (ECU) volar subluxation. Magnetic resonance imaging showed longitudinal splitting and dislocation of the volar half slip of the ECU tendon. The redundant radial SB was augmented and ECU sheath was advanced to the periosteum using suture anchors. He was able to perform his previous activities at the last follow-up. We encountered a case of simulateous ECU dislocation with extensor tendon subluxation of the long finger at the MP joint. Therefore, we report this case with a review of the relevant literature.

Ligament preserving technique for a locked metacarpophalangeal joint of the index finger.

Background Locking of metacarpophalangeal joint (MPJ) of the index finger occurs when volar radial osteophytes of the metacarpal head catch the accessory collateral ligament. We devised a ligament-preserving approach to quickly restore the MPJ motion while protecting the radial collateral ligament. Methods We retrospectively reviewed the results of nine patients treated for a locked MPJ of the index finger. In three patients, closed reduction was successful. In six cases, volar radial osteophytes were excised from the metacarpal head using a ligament-preserving technique through a longitudinal incision on the radial side. We analyzed osteophyte shape and height as demonstrated by X-ray and computed tomography (CT). Function was evaluated by examining the range of motion, recurrence, Disabilities of the Arm, Shoulder and Hand (DASH) score, and MPJ stability based on the key pinch strength. One male and eight female patients were followed for an average of 33 months (range, 12 to 65 months); the average age of patients was 41 years (range, 34 to 47 years). The average duration of locking of the MPJ was 23 days (range, 1 to 53 days). Results The sharp type of osteophytes was identified in six patients and the blunt type of osteophytes was indentified in three patients. The average height of radial osteophytes on the index finger metacarpal was 4.6 ± 0.4 mm in the axial CT image. At the final follow-up, the average extension limitation decreased from 26° (range, 10° to 45°) to 0°, and further flexion increased from 83° (range, 80° to 90°) to 86°. There was no recurrent locking after surgery. The DASH score improved from 24.3 to 7.2. Key pinch strength improved from 67.3% to 90.4%. Conclusions We obtained satisfactory outcomes in irreducible locking of the MPJ of the index finger by excising volar radial osteophytes of the metacarpal head using a ligament-preserving approach.

Flexible Intramedullary Nailing of Forearm Fractures at the Distal Metadiaphyseal Junction in Adolescents

Background The purpose of this study was to analyze the radiographic and functional outcomes of flexible intramedullary (IM) nailing in adolescent patients with forearm fractures at the diaphysis or at the metadiaphyseal junction (MDJ). Methods We retrospectively reviewed the results of 40 patients who underwent IM nailing for pediatric forearm fractures. Thirty males and 10 females were followed for an average of 16 months (range, 12 to 20 months). Their average age was 11 years (range, 10 to 16 years). The average duration from the onset of trauma to surgery was 3.8 days (range, 1 to 36 days). Fracture sites were located at the MDJ of the radius in 8 patients (MDJ group) while 32 patients had middle-third fractures (D group). We assessed the magnitude and location of the maximum radial bow and range of movements. Functional outcomes were evaluated using Daruwalla criteria. Results Open reduction was carried out in 8 cases. Union was achieved at an average of 8.3 weeks postoperatively. The results were classified as good in 38 and excellent in 2 according to Daruwalla criteria with restoration of forearm rotation. The mean angulation at the last follow-up was 1.8° on the anteroposterior radiograph and 3.3° on the lateral radiograph (MDJ group: 1.8° and 2.1°, respectively; D group: 1.9° and 2.8°, respectively). There was no significant difference in the mean angulation between the groups. The mean magnitude of maximal radial bow was 5.7% ± 1.8% (MDJ group, 5.2% ± 0.8%; D group, 5.9% ± 1.9%). The mean location of maximal radial bow was 58.0% ± 8.8% (MDJ group, 56.4% ± 8.9%; D group, 58.6% ± 8.9%). The differences in the mean magnitude and location of maximal radial bow with the normal contralateral arms (7.0% ± 1.2% and 50.9% ± 6.0%, respectively) were not significantly different between the groups. Complications included superficial infection (2), delayed union (1), and refracture (1). Conclusions IM nail fixation provided satisfactory results and maintained adequate stability for both forearm bone fractures in adolescents, even though the fracture was located at the MDJ of the radius.

Response to “Ligamentous repair of acute lateral collateral ligament rupture of the elbow”

In reply: We absolutely agree that to prevent overtreatment, acute surgical repair of the ruptured lateral collateral ligament (LCL) for traumatic posterolateral rotatory instability should not be done routinely. Our indications for repair of the ruptured LCL were gross instability of the elbow joint, persistent subluxation after reduction, and LCL avulsion associated with simultaneous radial head fractures. Between 2004 and 2012 (during this study period), 451 patients with acute elbow dislocation and an additional 198 patients with radial head fracture were treated at our institution. Among these patients, only 19 patients, of whom only 4 had radial head fractures, required surgical repair of the ruptured LCL. The remaining patients did not require surgical repair of the ruptured LCL. We found that traumatic posterolateral rotatory instability requiring surgical repair of the ruptured LCL is rare, and conservative treatment is sufficient for simple dislocation. We think that differentiation between simple dislocation and complex dislocation is difficult. Acute surgical repair of the ruptured LCL for elbow dislocation should not be done routinely.